Stage 2 – Posterior Tibial Tendon Dysfunction

Selene G. Parekh, MD, MBAAssociate Professor of Surgery

Partner, North Carolina Orthopaedic ClinicDepartment of Orthopaedic Surgery

Adjunct Faculty Fuqua Business SchoolDuke University

Durham, NC919.471.9622

http://seleneparekhmd.comTwitter: @seleneparekhmd

PTT Dysfunction

Most common cause acquired

adult flatfoot

Adult Acquired Flatfoot Classification

Stage

Tendon Deformity

I Degenerated

None (mild)

II Elongated, partial tear

Flexible, ↑heel valgus, possible forefoot

abduction III Elongated,

Partial tearStiff/fixed: minimal heel

inversion

IV Elongated,partial tear

Valgus ankle tilt

• A diverse constellation of deformity• Numerous names:

• PTTI, PTTD, Adult Acquired Flatfoot (AAFD), Adult Progressive Flatfoot, Collapsing Pes Valgus

Combined tendon/ligament failure

Stage II

• Variability in amount and types of flexible deformity

• Two groups• IIa• IIb_________________________________*J.T. Deland, et al. HSS Journal (2006) 2:157–160*Vora, et al. JBJS Am.,2006; 88:1726 - 1734 *Bluman EM, et al. Foot Ankle Clin. 2007 Jun;12(2):233-49, v. Review.

IIa

• Less than 30% medial talar head uncoverage (or no lateral incongruence)

• No clinical forefoot abduction

IIb

• More than 30% medial talar head uncoverage or lateral incongruence

• Significant clinical forefoot abduction

Lateral Incongruence

Congruent

IIa

Incongruent

IIb

Anatomy & Function

• PTT insertions• Navicular tuberosity, navicularcuneiform capsule,

medial, middle & lateral cuneiforms, cuboid, bases of 2nd-5th MT’s, & sustantaculum tali (Sarrafian)

• PTT function• Inversion of subtalar joint• Adduction of forefoot• Supination of forefoot

• Antagonist• Peroneal brevis

Function/Biomechanics

• Initiates heel rise• Invert subtalar joint• Locking transverse tarsal jts

• GSC powerful inverter after inversion initiated by posterior tib

• Patients w/ PTT dysfunction• Unable to initiate heel rise• Able to maintain heel rise once

on their toes

Pathophysiology

• Unopposed pull of peroneal brevis• forefoot abduction• Attenuation in medial ligamentous structures

• Progressive collapse of arch• End stage

• Marked calcaneal valgus• Talus PF• Forefoot abduction

Pathophysiology

• Spring Ligament Complex• Integrity of TN joint

• Superior medial calcaneonavicular ligament

• Inferior calcaneonavicular ligament

• Forefoot abd attenuation of spring ligament

• Talus PF & equinus contracture

Etiology

• “Critical zone of hypovascularity”• Medial malleolus to navicular

• Diabetes• Hypertension• Obesity• Trauma

Clinical Presentation

• Stage II: Flexible deformity• Postural changes

• Heel valgus• Loss of arch• Forefoot abduction/varus

• Tendinosis• Weakness• Normal subtalar motion• Pain

• Initially medial lateral pain later• Able to perform single toe rise early • Unable to perform single toe rise late

Physical Exam

• Observation (front & behind)• Deformity• Fullness behind medial malleolus

• Single toe raise• Evaluate TMT joints for

arthrosis/hypermobility (can mimic PTT dysfunction)

Physical Exam

• Range of motion• Muscle strength testing• Swelling @ PTT• Tenderness @

PTT/sinus tarsi

X-rays

• WB AP Foot• Talo-2nd MT angle• Lateral subluxation of

TN joint

X-rays

• WB Lateral Foot• Sag of TN joint• Talo-1st MT angle (Meary’s angle)• Height of medial cuneiform or MT overlap

X-rays

• WB Ankle Series• Hindfoot alignment view

• MRI • Controversial in its role

Conservative Treatment

• Orthotic w/ medial heel lift, longitudinal arch, medial forefoot post

• MAFO/Arizona brace • For more severe flexible deformities

• UCBL to block abduction of forefoot• Difficult to make

Chao & Wapner, CORR, 1999

Surgical Treatment

• Stage II: controversial• Early

• FDL transfer• Medial displacement calcaneal osteotomy

• Late• Add

• Lateral column• Lengthening/Evans• CC fusion

• TAL• Medial column procedure

• Cotton, Lapidus, PF osteotomy• Spring ligament

• Repair vs reconstruction vs TN fusion

Equinus

Strayer

• Gastroc• Sural nerve• Larger incision• More time

TAL

• Quick• Atrophy of gastroc• Loss strength

FDL Transfer

• Medial midline incision• Retract addHal• Knot of Henry• Formal tenodesis• Transfer through drill hole in navicular• Tie at end of case

• Foot maximal inversion

FDL Transfer

FDL Only

• Stage II (flexible deformity)• FDL transfer

• Results (Mann & Thompson)

• 88% satisfied• 7/11 not satisfied had fixed hindfoot or forefoot

deformity• No significant improvement in arch height

radiographically

Medial Displacement Calcaneal Slide

• Theory• Change the mechanical axis of the Achilles

• Improves inversion power

• Shifts weight bearing axis towards long axis of tibia

• Usage• Hindfoot valgus deformity 

Medial Displacement Calcaneal Slide

•Supine•Incision

•1cm posterior to peroneals•Through skin only•SURAL

•Mosquito to bone•Score periosteum•TPS saw

•Bounce blade•Osteotome

MCO

MCO

MCO

MCO

MCO

Medial Displacement Calcaneal Slide

• Shift in plantar flexion, lock in dorsiflexion• 5-10mm

• Fixation options• 6.5, 7.0 screws

• 1 or 2

• Edgelock• IO Fix

PTT Dysfunction

Failure Spring Ligament

• Superomedial Component• Abduction through

talonavicular joint

• Inferior Component• Plantar sag of

talonavicular joint

LCL/ Evans Osteotomy

• Theory• Lateral column shortened

• Usage• Anterolateral impingement• Forefoot abduction

• TN subluxation > 30-50% 

LCL/ Evans Osteotomy

•Supine•Incision

•Lateral over ant process•SURAL, PERONEALS

•Find CC joint•Retract peroneals inferiorly•Measure 1.5cm proximal to CC joint•Score periosteum•TPS saw

•Bounce blade

LCL

LCL

LCL

LCL

LCL

LCL

LCL

LCL/ Evans Osteotomy

• Distract • Lamina spreader• Hintermann distractor

• Check TN reduction• Distract and measure

• Autograft, allograft, biofoam wedges

• Fixation options• > 4.0 screws

• Laterally, axially

• Plates• Biofoam wedges

Lateral Column Procedures

• Lateral column lengthening• Restores arch height & talar head

coverage• Evans procedure

• Opening wedge calcaneal osteotomy

• CC joint fusion • Loss 30-50% subtalar motion• Complete loss transverse tarsal

motion

Courtesy of Chi, et. al., CORR, 1999

Lateral Column Pain

• Thomas RL, et al. Preliminary results comparing two Methods of lateral column lengthening. Foot Ankle Int. 2001; 22(2):107-19.

• 3/34 (9%) feet w persistent lateral pain

• J.T. Deland, et al. Posterior Tibial Tendon Insufficiency Results at Different Stages. HSSJ (2006) 2:157–160

• 8% w pain

• 45% (10 feet of 22) w discomfort

Other Ligaments• Other ligaments/joints likely fail: may be

combination• Flatfoot variants:

• Collapse through TMT joints

• Collapse through TN joints

Medial Column Procedures

• Stage II• Medial column procedures• Correct forefoot supination• Options

• PF cuneiform/Cotton osteotomy• PF 1st MT-cun arthrodesis• Nav-cun arthrodesis

Pictures courtesy of Chi, et. al., CORR, 1999

Spring Ligament Tear

• Repair – primary

• Reconstruction• PTT• Allograft/Autograft

• TN fusion

Spring Ligament Tear

Spring Ligament Tear

Spring Ligament Tear

Spring Ligament Tear

Surgical Treatment

• Stage II• Correct all deformity

• FDL transfer• Medial displacement calcaneal osteotomy• Add

• Lateral column• Lengthening/Evans• CC fusion

• TAL• Medial column procedure

• Cotton, Lapidus, PF osteotomy• Spring ligament

• Repair vs reconstruction vs TN fusion

RE ECT

the ankle

the foot